Form (Rev. April 2007)
8802
Application for United States Residency Certification
See separate instructions Foreign claim form attached
OMB No. 1545-1817
Department of the Treasury Internal Revenue Service
Additional request (see instructions) Electronic payment confirmation no. Applicant's name
Applicant's U.S. taxpayer identification number
If a joint return was filed, spouse's name (see instructions)
If a joint return was filed, spouse's U.S. taxpayer identification number
If a separate certification is needed for spouse, check here 1 Applicant's name and taxpayer identification number as it should appear on the certification if different from above
2
Applicant's address during the calendar year for which certification is requested, including country and ZIP or postal code (see instructions)
3a Mail Form 6166 to the following address:
b Appointee Information (see instructions):
Appointee Name ( Phone No.
)
CAF No. Fax No.
(
)
4 a
Applicant is (check appropriate box(es)): Individual. Check all applicable boxes. U.S. citizen U.S. lawful permanent resident (green card holder) Sole proprietor Other U.S. resident alien. Type of entry visa Current nonimmigrant status and date of change (see instructions) Dual-status U.S. resident (see instructions). From to Partial-year Form 2555 filer (see instructions). U.S. resident from to Partnership. Check all applicable boxes. U.S. Foreign LLC Trust. Check if: Grantor (U.S.) Simple Rev. Rul. 81-100 Trust IRA (for Individual) Grantor (foreign) Complex Section 584 IRA (for Financial Institution) Estate Corporation. If incorporated in the United States only, go to line 5. Otherwise, continue. Check if: Section 269B Section 943(e)(1) Section 953(d) Section 1504(d) Country or countries of incorporation If a dual-resident corporation, specify other country of residence If included on a consolidated return, attach page 1 of Form 1120 and Form 851. S corporation Employee benefit plan/trust. Plan number, if applicable Check if: Section 401(a) Section 403(b) Section 457(b) Exempt organization. If organized in the United States, check all applicable boxes. Section 501(c) Section 501(c)(3) Governmental entity Indian tribe Other (specify) Disregarded entity. Check if: LLC LP LLP Other (specify) Nominee applicant (must specify the type of entity/individual for whom the nominee is acting)
Cat. No. 10003D Form
b c d e
f g h
i j
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
8802
(Rev. 4-2007)
Form 8802 (Rev. 4-2007)
Page
2
Applicant name: 5
Was the applicant required to file a U.S. tax form for the tax period(s) on which certification will be based? Yes. Check the appropriate box for the form filed and go to line 7. 990 990-T 1040 1041 1065 1120 1120S 3520-A Other (specify) No. Attach explanation (see instructions). Check applicable box and go to line 6. Minor child QSub U.S. DRE Foreign DRE FASIT Foreign partnership Other
5227
5500
Section 761(a) election
6
Was the applicant's parent, parent organization or owner required to file a U.S. tax form? (Complete this line only if you checked "No" on line 5.) Yes. Check the appropriate box for the form filed by the parent. 990 990-T 1040 1041 1065 Other (specify) Parent's/owner's name and address 1120 1120S 5500
7
and U.S. taxpayer identification number No. Attach explanation (see instructions). Calendar year(s) for which certification is requested. If certification is for the current calendar year, a penalties of perjury statement is required (see instructions). Tax period(s) on which certification will be based (see instructions) Purpose of certification. Must check applicable box. Income tax Other (must specify) VAT (specify NAICS codes)
8 9
10
This space can be used to enter additional required information
Sign here
Keep a copy for your records.
Under penalties of perjury, I declare that I have examined this application and accompanying attachments, and to the best of my knowledge and belief, they are true, correct, and complete. If I have designated a third party to receive the residency certification(s), I declare that the certification(s) will be used only for obtaining information or assistance from that person relating to matters designated on line 9. Applicant's signature (or individual authorized to sign for the applicant) Applicant's daytime phone no.:
Signature Name and title (print or type)
Date
Spouse's signature. If a joint application, both must sign.
Name (print or type) Form
8802
(Rev. 4-2007)
Form 8802 (Rev. 4-2007) Applicant Name
User Fee Voucher for U.S. Residency Certification Application
Applicant TIN
Page
3
For IRS use only: Pmt Amt $ Date Pmt Verified: / /
Appointee Name (If Applicable)
Calendar year(s) for which certification is requested (must be the same year(s) indicated on line 7)
11
Enter the number of certifications needed in the column to the right of each country for which certification is requested. Column A Column B Column C Column D
Country
Armenia
CC
AM
#
Country
France Georgia
CC
FR GG
#
Country
Lithuania Luxembourg
CC
LH LU MX
#
Country
Spain
CC
SP
#
Australia
AS
Sri Lanka
CE
Austria
AU
Germany
GM
Mexico
Sweden
SW
Azerbaijan
AJ
Greece
GR
Moldova Morocco
MD MO
Switzerland
SZ
Bangladesh
BG
Hungary
HU
Tajikistan
TI
Barbados
BB
Iceland India Indonesia
IC
Netherlands
NL
Thailand
TH
Belarus
BO
IN ID
New Zealand
NZ
Trinidad and Tobago Tunisia
TD TS
Belgium
BE
Norway Pakistan
NO
Bermuda
BD
Ireland
EL
PK
Turkey
TU
Canada
CA
Israel
IS
Philippines
RP
Turkmenistan
TX
China
CH
Italy
IT
Poland
PL PO
Ukraine
UP
Cyprus
CY
Jamaica
JM
Portugal
United Kingdom
UK
Czech Republic
EZ
Japan
JA KZ KS
Romania
RO
Uzbekistan
UZ
Denmark
DA
Kazakhstan
Russia
RS
Venezuela
VE
Egypt Estonia
EG EN
Korea, South Kyrgyzstan
Slovak Republic
LO
KG
Slovenia
SI
Finland
FI
Latvia
LG
South Africa
SF
Column A - Total
Number of Forms 6166
1 - 20 21 - 40 41 - 60 61 - 80 81 - 100
Column B - Total
Number of Forms 6166
101 - 120 121 - 140 141 - 160 161 - 180 181 - 200
Column C - Total
Column D - Total
User Fee
$ 35.00 $ 40.00 $ 45.00 $ 50.00 $ 55.00
User Fee
$ 60.00 $ 65.00 $ 70.00 $ 75.00 $ 80.00
12a Enter the total number of certifications requested (add columns A, B, C, and D of line 11) b If the total number of certifications is 20 or less, go to line 13 c If the total on line a is greater than 20, enter $5 for each additional 20 certifications (see instructions) 13 Amount owed. Add lines 12b and 12c
Form
12a 12b $35
12c 13
8802
(Rev. 4-2007)